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消化管瘻 102例에 對한 臨床的 考察

A Clinical Evaluation on 102 Cases of External Alimentary Fistula

대한외과학회지 1970년 12권 8호 p.5 ~ 17
김세호,
소속 상세정보
김세호 (  ) - 서울대학교 의과대학 외과학교실

Abstract


This report presents clinical observation and evaluation on 102 cases of the external alimentary
fistula among 118 cases, which were managed at Surgical Department of the National Medical Center
during a full 10 year period from January 1959 to December 1968.
Aretaeus of cappadocia (circa 30∼39 A.D.) first produced external fistula by incising a abscess of
the right lower quardrant and then Seracenus (1642) described for the first time a fecal fistula in
his literature.
Afterward, many studies were followed by Cladius Amyland(1735), Copeland(1812), and Ginzberg
(1940)etc.
"External Alimentary fistula" represents abnormal communication from some part of G.I . tract
to the skin or others. In this paper, however, pancreatic and biliary fistulas as well as congenital
and internal intestinal fistulas were excluded. And to differentiate simple bowel perforation which
may develop into a local abscess, generalized peritonitis or a fistula from it, here are arbitrarily
confined to the situation that they have external drainage of gestric or enteric contents for 48 hours
or more.
External fistula has been one of the most serious and challenging problem in surgucal service
for many decades, despite of progressive improvements in surgical technique and various antibiotics
with modern knowledgements of replacement therapy.
The results of this reports are summarized as followings:
1. Incidence in this paper was not obtainable because, in the majority (95.1%) of cases, the initial
operation was performed elsenwhere.
2. The ratio of male and female was 1.5 to 1. 60(58.8%) being male and 42(41.2%) female.
The average age of patients was 35.3 years. In around 75% of cases age was ranged from 21 to
50 years.
3. The average duration of the fistular history before referring to N.M.C. was 10.5 months.
4. R.L.Q. (52.2%) was the most frequent place in the site of external opening and origination
of internal opening arised from small bowel 45(44.2%) and from large bowel 39(38.4%) with
complex type 13(12.6%) which has two or more origination in G.I. Tract.
5. In draining materials via fistular openig, feces occupies the highest percentage (49.1%) of
its kind and pus (20.5%), both (17.8%), intestinal juice (6.9%) and indigested food (1.9%) in
this order.
6. Surgical complication 57(55.9%) and inflammation 30(29.5%) were implicated as most impo
rtant etiological factors. In the former surgical injury was direct cause of fistular formation in the
majority of all sites except for cecum and stomach. Among inflammation, appendicitis was blamed
for it most frequently, especially in cecum.
7. Twenty kinds, including one undetermined case, of original diseases preceding operaiton,
followed by fistula were identified. The top of them was appendicitis and mechanical ileus, perito
nitis, Gy & Ob diseases and malignant tumors in its lowering frequency.
8. In the majority of cases, fistulography was performed before management or operation with
positive results of 96.5% and in some selected cases, red juice test done for definitive diagnosis and
better knowledge of fistular condition such as location and degree of it by checking time and amount
excreted outside.
9. The type of fistular tract was classified largely into: 1) single or multiple 2) external or int
ernal or combined. Almost are belong to single and external type with 87.2% and 94.1% respectively.
10. The significant complications of these fistulaes are infection (50.7%) skin irritation or diges
tion (15.5%) and fluid and electrolyte imbalance (11.2%), followed by cardiopulmonary disease
(7.4%). Infection, containing septicemia, peritonitis and wound infection, was most often encount
ered in large bewel, concommitantly becoming most important causes of death there, while fluid
and electrolyte imbalance in small bowel especially, in upper part of it.
11. Operative management led to ve cure in 75.2% of 89 cases with recurrence of 6.7%. Among
6 cases of recurrence, 4 were on same site and 2 on other site. Mentioning on surgical methods,
small boxwel and complex fistula are, at large, treated satisfactorily by early resection of intestine
with anastomosis from which it arises and simple closure upplied to large bowel fistula with
rather good results.
Conservative treatment with resultant spontaneous closure was 11(84.6%) of 13 and 2 cases of death.
large bowel and complex were 17.8% 18.1% and 23.1% respectively. The mortality races of cases
treated surgically and conservatively were 17.9% and 15.4% in each.

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